Learn technology – It will revolutionise the way we doctors practise by 2020

Dr Debraj Shome
CEO
MediAngels

Dr Debraj Shome is a renowned Indian facial plastic surgeon and CEO of MediAngels.com, an online hospital providing medical advice and second opinion to patients. He founded MediAngels along with Dr Arbinder Singal, a top Indian paediatric urologist, in January 2011.

Dr Shome specialises in facial cosmetic surgery, facial plastic and reconstructive surgery, facial and ocular oncology (cancers), occuloplastic surgery, eyelid and orbital surgery. He has started The Esthetic Clinics, which is a chain of plastic surgery and skin care centres all over Mumbai. Dr Shome is also a consultant in facial plastic surgery at Nova Specialty Hospitals, Mumbai. He also practices at other top Mumbai hospitals like Holy Family Hospital, Breach Candy & Saifee Hospital. He was earlier the head of Institute for Aesthetics and Cosmetic Surgery at Apollo Hospitals, Hyderabad. Before that he was associated with the department of facial plastic surgery at the Tata Memorial Hospital, Mumbai. He is also visiting faculty to the department of head and neck surgery at the M D Anderson Cancer Centre, Houston, Texas, US.

Dr Shome completed his undergraduate medical education from Grant Medical College and Sir JJ Group of Hospitals, Mumbai. Dr Shome obtained the degrees of FRCS (Fellow of Royal College of Physicians and Surgeons of Glasgow) in 2003 and also the Diplomate of National Board (DNB) in 2004. He is amongst the only plastic surgeons in the world, with fellowship training in four separate facial surgery disciplines: occuloplastic surgery, head & neck surgery, facial plastic surgery and maxillofacial surgery. He has also completed his MBA in Healthcare Management from Vanderbilt University, Nashville, Tennessee, US.

Dr Shome claims to have over 40 national and international peer reviewed publications in basic and clinical research in facial plastic surgery, occuloplastic surgery and cosmetic surgery, numerous presentations at conferences and many awards such as ‘Best Plastic Surgeon in Mumbai”, “Top 10 Cosmetic Surgeons in India”, “Best Occuloplastic Surgeon India”, etc.

India Medical Times spoke to Dr Debraj Shome to understand why he became a healthcare entrepreneur and his vision of healthcare delivery by 2020.

How did MediAngels come into being?

MediAngels is not just any other ambitious venture – it is an idea born out of real problems faced by real people like you and me. It is about health, the one thing that money sometimes cannot buy and about quality healthcare, the presence of which defines life and the absence of which pretty much can be life threatening. Let me share with you how MediAngels was started and how we plan to make a difference in the lives of people.

It all started seven years ago when I was working in the United States. Things were going well, until I suddenly learnt one day that my father had been diagnosed with non-small cell lung cancer. The cancer was in an advanced stage and had afflicted four major organs, including his lungs, liver, kidney and spine. Doctors at leading hospitals in India quickly gave up all hope and gave my father less than 60 days to live. It is always hard for a son, when a father develops a life threatening disease. It was even worse for me, being the only child. Being a physician who treated facial cancers myself, I tapped my wide network of friends from the medical fraternity and sought an opinion from Dr X (not named for privacy reasons), the pioneer of non-small cell lung cancer research at the MD Anderson Cancer Centre in Texas, US, a place where I had worked before. Dr X was in the process of conducting trials on the effect of thalidomide on malignant lung cancer cells. This research was in Stage II trials and evaluation and obviously no literature had been published on this mode of treatment before. I, being a physician myself, as well as knowing Dr X personally, requested her to advise the ‘off-protocol’ therapy for my dad and then coordinated the communication between Dr X and the team of oncologists at Hinduja Hospitals, Mumbai and for the very first time, implemented this new mode of treatment, right here in India. A dedicated team of specialists working on an unconventional treatment plan resulted in nothing short of a miracle – my father made tremendous progress and was cancer free in six weeks. This was nothing short of a miracle, for a man who had stage IV disease, to be cancer free! My father subsequently passed away in 2011, but to get three and a half years of quality time with him is a memory I will treasure lifelong!

Something similar happened in the case of my co-founder, Dr Arbinder Singal.

Now, our fathers were able to get the best medical advice and care because we had access to the best doctors globally, from our personal networks. But, what these episodes made us realise is that medical care today has become so super specialized, that there may be one doctor somewhere in the world who has more experience and training in your disease. Reaching that doctor may make all the difference in your outcomes! But how will you reach that doctor? We managed because we had access to many doctors, being physicians ourselves. But what about you and your father? You could be the richest person in the world, but how would you reach the appropriate specialist for your disease? In our case, our contacts and profession helped us. But does a common man know whom to consult? How can they be sure that their doctor is trained and experienced enough? Lack of access is one of the biggest flaws in healthcare today. That is when we thought of starting MediAngels – an online hospital – which would have the best doctors in the world for each disease – such that patients could get mapped to the best doctor for their disease and get the best possible advice and latest evidence based treatment recommendations.

MediAngels makes top doctors accessible to more people over the internet or even on the phone. It uses an integrated technology platform, which connects a credentialed, qualified and validated super specialist doctor network connected with a diagnostic and laboratory network across the country, and integrated with electronic medical records.

Adversities are often catalysts for a revolution – that pretty much sums up the story of MediAngels, the world’s first online hospital.

How is MediAngels doing so far? What has been the response of doctors?

MediAngels has now rapidly grown to a super-specialist physician network of 350+ doctors from 93 specialties spanning across 15 countries. This is a “by invitation only” doctor panel, chosen by the MediAngels Medical Advisory Board. The way we empanel our physician partners is that if there is a physician doing path breaking work in a particular disease, publishing papers and leading quality research in that field, we will write in to him and get him in.

MediAngels is also important for physicians, as it allows these top-class busy practitioners to see more and more patients from across the globe. There is an obvious benefit to physicians to be on a panel, where the criterion for empanelment is so stringent.

MediAngels does everything that the outpatient department of a hospital does. It is based on connecting patients seeking medical services to its panel of specialists across the globe. No matter where the patients live and how far a doctor may be from them, they can now have access to the best in healthcare, if doctors have access to a phone or the internet. Some of these patients may want to actually travel to get treated by the doctor, leading to substantial revenue generation for our doctors.

We also promote our MediAngels physician colleagues via press interviews and events to boost their brand. We also make websites for them, such that their digital presence improves. All in all, the idea is that the practices of our doctors should benefit from their presence on MediAngels – some of these patients may decide to consult them via MediAngels, but many more may just walk into their private clinics and hospitals to consult them directly! So, in that sense, we at MediAngels look at ourselves as partners with our panel physicians in augmenting their brand.

Recently, MediAngels was in the eye of storm over its data which found that 44% of the surgeries are “unnecessary”. So did it mean that doctors recommend unnecessary surgeries?

First, let me talk about the data.

The data was of our patients, who had sought a specialized opinion from our doctors, over the past two years. These patients came in from all over the world, with a majority (96%) being from India. Because these were patients, who were already advised a surgery by their current doctors, maybe their seeking a second opinion reflects a selection bias in the data.

On MediAngels, the patients can choose which doctors they want an opinion from. So, these patients chose the doctors, after checking their accreditation, qualification and even certification.

The MediAngels physicians responded to the patients directly. At this stage, it is imperative to note that all of our doctors are empaneled with us, but they are not paid any salaries. They are not MediAngels employees, and it is a principal to principal arrangement, just like physical hospitals have with their physician panel. So, it is not as if MediAngels can alter or influence the physician recommendations in any way.

There are two ways our data can be interpreted:

A) Maybe, since there are super-specialists for every disease on our panel, the appropriate disease was reaching the appropriate doctor and this in turn probably meant that patients were getting appropriate treatment recommendations, other than surgery. Medicine after all is becoming more and more super-specialized today, and we doctors (as specialists) know “more and more” about “less and less” (know more and more about the areas within our specialty).

B) It is possible that some of our colleagues were making possible commercial decisions in suggesting surgeries, where none may have been required. In such cases, the fact that at MediAngels the decision is virtually made (i.e. the doctor was in a city not the same as the patient) may have prevented this bias from creeping in.

Look, I am a practising surgeon myself. I personally feel that our fraternity gets a lot of unnecessary flak. The truth is our fraternity is drawn from the rest of society. So, just like in society, there are both good and not so good elements. It does not make the entire fraternity wrong or corrupt. There are bad and good politicians, does that give us enough license to say that all politicians are behaving inappropriately?

But yes, it is indeed possible that some colleagues may be recommending unnecessary surgeries. If they are doing so, they should realise that they are harming our entire community by indulging in unfair practices. Because, people go ahead and then paint all doctors as being greedy – nothing could be further from the truth!

Your message to the Government of India on the medical community?

Doctors are an asset to society and it is time the government treats them as such. I feel the government, as a whole, is unfair at times to doctors.

For instance, please tell me why does the government not mandate compulsory rural service for our IITians and IIMians? With respect to doctors, they say they spend on our education and so the mandated service “to the nation”. But does this mean that the government does not need to spend on creating top quality engineers and management graduates? If you have rules and policies, they must be the same for all professionals.

I have heard reports of the government wanting to mandate and control the fees doctors can charge. But it is a service, isn’t it? Like any other service, the service will be available at different price points. Can we go to a five star restaurant and demand food at the food court’s price? Funnily, in certain professions like lawyers, if they charge more, they are seen as being “more in demand”. In our profession, if we charge what we wish to (incidentally, in such cases, the patient too agrees to pay that price), we are labelled as being greedy! Why?

I have also heard of the government wanting to impose service tax on medical consultation services. Sure, please go ahead and do that. So, this makes medical practice a “service” and patients “consumers”, right? Therefore, once you do that, please do not expect doctors to perform free camps mandatorily and assist you when there are flood or natural disasters, for instance. Please also ensure that you will provide us protection from lumpen elements who think they can get away at any time by assaulting us and hospitals.

I think the rules need to be the same for all. And, a holistic view needs to be taken to govern and improve medical care.

If the government wants better doctors, who are not greedy, the start has to be made from medical education. In today’s system, where politicians run medical institutes, the economics of the education business forces doctors to be greedy in practice, to recover their “investment” and to make ends meet.

Is MediAngels bootstrapped? What are the problems you are facing?

I feel venture capital and investing firms in India tend to also have a “herd mentality”. Once one VC firm gets on the bandwagon of a particular business category and scores a success, everyone else wants to jump in. Until then, no one wants to evaluate new, disruptive business ideas. The reasons why this might be so, are manifold:

A) Most VC firms in India do not appear to have specialists in the job. For instance, very few VC firms have specialists who look at healthcare. This is very different, when compared to Silicon Valley, where many firms have specialists.

B) India itself is an emerging market. So, we tend to have a “safe” mentality towards business and towards investing. But we need to understand that big successes need big risk taking appetite and a love of failure. To build a Google or a Facebook like brand, we cannot have a “mutual fund” like mentality of getting your safe 30% returns annually!

Hence, I feel, for new business verticals to survive in India is a challenge.

MediAngels was initially bootstrapped and we raised money from selves and our family and friends. We were lucky to be funded fairly early by HDFC Private Equity, for a seed round, in 2011. But, post that, raising funding became very difficult, as the business numbers did not stack up. Of course, to expect a healthcare business to multiply the way e-commerce can is an anomaly. Healthcare is all about trust and credibility and it takes time to get the flywheel of revenue generation going!

When we could not raise money for our 2nd round, we faced immense problems. We got stuck into a debt vortex, having taken high interest debt from a financial firm. And when we could not service the Rs 75 lakh debt, we found ourselves in court and facing arrest in 2013. Those were tough days! I remember Arbinder and I being in court and finding plaster falling off the court ceiling on to our heads. The first thought which crossed our mind was that if this is how the court was, imagine how jail would be!

It was surreal, in some sense. On one hand, we were facing jail for a Rs 75-lakh debt used in running the company and trying to create a healthcare revolution; on the other hand, folks with much larger debt defaults were seemingly having it much easier! And all this for a company, which was looking to make healthcare more affordable and accessible to all Indians! In fact, funnily enough, MediAngels had been chosen as the “most innovative company” in the entire Asia-Pacific region, from amongst 8000 startups in 2012.

Those two years were the worst years of my life! Getting up every day and trying to stay motivated was a huge challenge. But these tough days also strengthened our resolve. We survived. Those days also proved to us how important MediAngels was to us. We did not run back to our clinical practices, despite adversity – this could have been an easy path to take, considering both Arbinder and I were well-recognized super-specialists in our fields!

Post this, we received funding from the Government of India in 2014 — The Technology Development Board, established under the aegis of the Union Governments’ Department of Science and Technology, came in to financially support us. This was a big morale boost to us, to have the government support us. Subsequently, another top VC firm, VenturEast and its managing director Mr Sateesh Andra, showed belief in us and invested into MediAngels in 2014.

How tough is it for a startup in medical technology to survive and grow amidst seemingly unfavourable investment climate and support

For a young startup, raising funds is a daily struggle. Therefore, a startup needs passionate entrepreneurs – entrepreneurs, who have the belief to trust their vision and gut instincts, more than the millions of naysayers they will encounter daily. For instance, I believe that the “online hospital” idea is very innovative and solves the problem of healthcare delivery in India. This may seem inconceivable to physical brick and mortar hospitals today. But let’s not forget, Walmart too did not conceive that Amazon would become larger than it, at one point in time.

We are concentrating funds currently to building bigger and better hospitals! Those, of course, are important. But my question remains, how will we build these hospitals in every district in India? And even if we manage to do that, where are the quality doctors who will serve in these hospitals? Therefore, in my opinion, to provide access, affordability and convenience, the use of technology in healthcare delivery is a given!

The problem in India is seed funds don’t really exist. Venture capitalists don’t really fund seed businesses. Initially, when we went to venture capitalists, they kept telling us that we needed to show the product before raising funds. But the problem was how to show the product without having the money. We put in our own money and raised some from friends and family.

We were lucky that HDFC’s private equity unit decided to come in. Other great business ideas may not be as lucky! The fact that you are able to deliver service that changes lives hasn’t been conceived or even dreamt of in healthcare. Innovators have good ideas, but they don’t get funds to give them a practical shape. So, the overall scenario is poor.

How do you switch between the role of an entrepreneur and a doctor with so much ease? Share with us some of your working mantras?

Initially, when we started MediAngels in 2011, I put my plastic surgery practice on a hold. That seemed the right thing to do, to realise our vision. I am also a one-trick pony, in some sense – multi tasking is not easy for me!

Then, we hit 2012, when we ran out of funds. This left me with no choice but to get back to medical practice – that was the only way I could stay afloat financially and that was also the only way to infuse funds into MediAngels to keep it alive.

When I restarted practice, I also quickly realised that it was important to be practising as a physician – that is what assists, maintains contacts within our fraternity! So, now I make a conscious attempt to practise as a plastic surgeon, a substantial portion of my working time. I, of course, love surgery and was trained for 11 years to become a facial surgeon, so this balance makes it worthwhile.

Actually, it is very easy, now that I am in this. When I am in surgery, I completely switch off and am completely concentrated on the surgery and task on hand. The same goes to when I am in my role as the CEO of MediAngels. The key is to stay in the moment and concentrate in the moment.

Could you share with us the lowest points of your life and how did you stay motivated?

The lowest point of my life was the death of my father. One realizes the importance of parents only when any one of them passes away. I was totally disappointed and disheartened by it. In fact, it brought a lot of changes in me personally. The other lowest point is the financial difficulties we have faced in running MediAngels.

These setbacks have probably made me more spiritual and a bigger believer in God and destiny. When things are going well, it is easy to think that “I” am doing everything. But we all need to understand that “I” do not make the sun rise, the world was running even without “I” being in the picture and will continue to run the way it is, even when “I” am not there in this world! Once we accept that we can only control processes and not the results, we become less stressed and more accepting. It is our job only to do our karma!

So, there is no point in being stressed or worried. After all, being a doctor, I could not save my own dad! I know the Bhagavad-Gita says this in detail, but it takes real life tragedies to truly understand the Bhagavad-Gita!

Please share with us your biggest achievements so far?

Everything in life can be looked at as an achievement, and yet nothing truly is an achievement! We are just pawns, doing with the Supreme Power has decreed on us. So, in some sense, our achievements are fortuitous and the Almighty needs to be thanked for the same.

Professionally, I think the training (as a surgeon) I have received has been a matter of great fortune. Getting trained under so many specialties (facial plastic surgery, maxillofacial surgery, head & neck surgery and occuloplastic surgery) via Fellowships has allowed me to hone my skills and fulfil my desire to become a better face surgeon.

I have been fortunate to be chosen for the Colonel Rangachary Award (the highest award for research) and multiple other awards by multiple physician societies. To have contributed my bit to top quality research in retinoblastoma and facial cancers, including formulating a new drug molecule with the IIT Mumbai, is something I am very fortunate to have been a part of.

I have also been fortunate to have formulated a new drug composition for hair growth (the QR 678 hair growth factors) and conducted clinical trials on the same. The same is now under consideration for a global patent.

Awards like the Davies Award — awarded by the Royal College of Surgeons, Glasgow (I was the youngest awardee and the 1st from Asia) for revolutionary research work in oncology — have kept us motivated.

I could never have imagined the path life has chosen for me. In fact, when I proceeded for my MBA in 2007, the idea was to come back to India and start a chain of plastic surgery centres. I had no idea that life would throw me a curve ball, making me face healthcare issues, as part of my dad’s suffering and make me want to come up with a solution like MediAngels.com. Starting MediAngels, getting funded and trying to change healthcare delivery has been an extremely fortunate thing – MediAngels has taught us a lot about business and life in general, and must rank amongst my fortunate moments and “achievements”.

What is on the cards now, for healthcare, by 2020?

If we look at healthcare delivery, I feel it has pretty much remained the same for decades. For instance, while the government has Primary Healthcare Centres, the same still don’t have doctors! So, there is a pipe but is oil flowing through that pipe? In my opinion, the only way to make the best doctors available everywhere is through the use of technology.

Even in cities, even today, in the 21st century, patients take two hours to reach a doctor, and spend hours before they can be seen by the doctor. The doctor, too, is not able to see patients from all over the world. So, in cities there is too much competition amongst doctors (which drives unethical practices) and at the same time, there are not enough specialists in rural areas.

Technology can lessen the waiting time, make the system more efficient, such that doctors can earn more and yet patients can pay lesser. Imagine a doctor attending his OPD and consulting patients from all across the world, without leaving his home – A Virtual OPD!

I feel technology will play an important role in healthcare delivery and revolutionise healthcare, as we know it.

Your message to the medical community?

We are living in an exciting age. This is the age of true ‘medecins sans frontieres’ (doctors without borders). The patient will be able to reach us doctors from all over the world, using technology; where we practice will only remain a location address! It is an exciting time to be alive!